CLINICAL NOTES ON CHOLERA
Authors: W. L. Lindsay
Journal: BMJ (1854)

M~~~~~~~~1II:rA ac*flkm !b heouvenience produced by this aagging" upon tihe tdne i'm matojnther obvited by the opetion now u t on.The hmmorrhoid miy be removed, if neces- J, without even being protruded through the external w~ening.The pain and irritation caused by leaving the lgate upon the part to be removed is also dispensd with.2. Although the ordinary operation for hemorrhoidal umours is reckoned safe, yet instances every now and then occur in which very severe and even fatal effects follow.01r B. Brodie mentions having, in his own very large ex- perence, had three fatal cases.I have myself had the opportunity of dissecting the parts after a fatal result in three other instances wvhere the operation had been per- formed by the most able and cautious surgeons of the day.In two of these instance;, secondary deposits had occurred in internal organs, and in the third there were symptoms of blood poisoning during life, and an open vein of some size was found after death, leading directly from the wound caused by the operation.When the base of a hemor- rhoidal tumour is transfixed with a needle, any large vein which it may happen to contain is necessarily liable to be wounded; and if, after this is done, each half of the tumour i included in a separate ligature, it is extreiaely likely that dle sides of such a vessel would be held open.This cir- cumstance, in the subsequent stages of the complaint, would, as far as-it goes, directly favour the absorption into the circulation of the inflammatory products of the part.If, on the other hand, the whole of a hmmorrhoidal tumour b included in a ligature, there is a possibility that it may not be completely strangulated.The outer parts of the tumour may slough, while a languid and partial circulation is continued in a conical portion in its centre.The blood which there circulates though tissues on the verge of mortification, but which have not entirely lost their vitality, may become infected by the products of decomposition with which it comes in contact, and may thus, being again re- ceived into the circulation, become the source of general disorder in the system.This point is well illustrated by cases in which a ligature has been applied to portions of the tongue.It has been found that, as ulceration occurred in those parts directly subjected to pressure, the ligature has gradually become loosered.The circulation has then agan in some measure been restored in the centre of the ligatured part, and this has been followed by symptoms of general constitutional disturbance.After the application of a ligature to a large tumour in any part of the body, such a partial restoration of circulation may take place.There is no distinct and immediate line of demarcation drawn between the living parts and the dead; and it may be left to accidental causes to determine how much of the tumour will recover its vitality, and how much of it will perish.That a general contamination of the blood, from some cause or other, occurred in the three cases above referred to, that I had myself an opportunity of examining, I can- not doubt; and I believe that this source of danger would be entirely prevented by performing the operation in the manner which has now been described.The application of the actual cautery, while it prevents any blood flowing from the divided vessels, also prevents any vitiated fluids passing through them into the general circulation.* 3.After the application of a ligature to a portion of mucous membrane, a process of ulceration is commenced, and continues until the ligature separates.During this period, no process of repair can be commenced.No two actions, as Hunter has so well said, can go on in the same part at the same time.While the part is undergoing ulcer- Mtion produced by the presence of the ligature, no attempt U reparation can take place.At the time the ligature *I use te tem "c oneutive fever", not bweause I believe in the exist.